Analysis of the causes of immediate unanticipated bleeding after pediatric adenotonsillectomy

Hemorrhage after adenotonsillectomy in children: tertiary center experiences

BACKGROUND

Adenotonsillectomy is the most commonly performed surgery in the pediatric population. Hemorrhage after adenotonsillectomy, which can occur at any time postoperatively, is one of the most serious complications.

OBJECTIVE

To determine the frequency of hemorrhage in children after adenotonsillectomy and to compare postoperative hemorrhage with regard to age and sex.

METHODS

A cross-sectional longitudinal study was conducted at the Ear, Nose, and Throat Clinic, University Clinical Center Tuzla, and included all children of both sexes, aged 3 to 15 years, who underwent adenotonsillectomy during a 1.5-year period.

RESULTS

A total of 201 children aged 3-15 years underwent adenotonsillectomy, 113 males and 88 females, which corresponds to a ratio of 1.28: 1. Adenotonsillectomy was performed in 147 (73.1%) patients and adenoidectomy in 54 (27%). In the overall sample, there were 19 (9.5%) subjects with postoperative hemorrhage. Primary hemorrhage occurred in 9 subjects (47%) and secondary hemorrhage in 10 subjects (53%). Significantly more female subjects had postoperative hemorrhage. In the group of subjects with hemorrhage, the mean age (standard deviation) was 8.45 (3.3) years. Tonsillar lodges are common sites of hemorrhage.

CONCLUSION

The frequency and causes of hemorrhage after adenotonsillectomy in our study are partially comparable to the world data.

Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review

In the field of otolaryngology—head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient’s real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.

Risk Factors for Postoperative Bleeding after Adenoidectomy

IMPORTANCE: Postoperative bleeding is a common and potentially life-threatening complication. Precise identification of risk factors in addition to the basic ones, such as coagulation parameters, is certainly very desirable. OBJECTIVE: The aim of this study was to identify other possible risk factors for bleeding after adenoidectomy in children. DESIGN: This observational prospective study enrolled children undergoing adenoidectomy from October 2019 to February 2020, then evaluated the influence of possible risk factors for bleeding. SETTING: Tertiary pediatric otorhinolaryngology center. PARTICIPANTS: A total of 288 children aged 0–18 years undergoing adenoidectomy for recurrent upper respiratory tract infections, recurrent acute otitis media, secretory otitis media, and obstructive sleep apnea syndrome. MAIN OUTCOMES AND MEASURES: Increased blood pressure and time of surgery were identified as risk factors for bleeding after adenoidectomy. RESULTS: Elevated systolic (p = 0.046), diastolic (p = 0.012), and mean arterial blood pressure (p = 0.007) (Mann–Whitney U test) as adjusted for age-specific distributions and with corrections for height and weight, as well as time length of surgery (p < 0.001) (Fisher’s exact test) were revealed as statistically significant risk factors for postoperative bleeding. Atmospheric pressure, surgeon’s level of experiences, chronic inflammatory content in adenoid vegetation (AV), size of AV, recidivism of AV, recurrent infections of the upper respiratory tract, type of anesthesia, long-term using of drugs, and positive coagulation questionnaire or pathology in standard coagulation tests were not found to be risk factors for bleeding after adenoidectomy. CONCLUSIONS AND RELEVANCE: In this prospective study within a well-defined population of children, we evaluated increased blood pressure and time of surgery as risk factors for bleeding after adenoidectomy. These data bring new information that complements current knowledge in this field.

Effective hemostasis in children with Von Willebrand factor defects undergoing adenotonsillar procedures

INTRODUCTION

Children with low von Willebrand factor (VWF) activity or type 1 von Willebrand disease (VWD) have increased risk of bleeding after adenotonsillar procedures and the optimal perioperative management to minimize bleeding is unknown.

AIM

To report the effectiveness and safety of an institutional protocol in minimizing postoperative bleeding in children with type 1 VWD or low VWF activity.

METHODS

We conducted a retrospective chart review in children with type 1 VWD or low VWF activity treated via an institutional protocol that utilizes repeated doses of Desmopressin acetate (DDAVP, 1-deamino 8-D arginine- vasopressin) or VWF concentrate, brief hospitalization for observation and extended use of oral epsilon aminocaproic acid (EACA).

RESULTS

From 2010 to 2017, 13 children underwent an adenotonsillar procedure and were treated with this protocol. Although 7.6% had minor immediate bleeding and 23% had minor delayed bleeding, no patients experienced major bleeding or required transfusion, additional surgery or other measures not specified by the protocol. Mild hyponatremia was observed in 80% of patients who received DDAVP.

CONCLUSION

Our institutional protocol specifying repeated dosing of DDAVP or VWF concentrate to sustain elevated VWF levels during periods of highest bleeding risk and extended use of EACA is effective at preventing major bleeding episodes after adenotonsillar procedures. However, this analysis raised safety concerns that prompted changes in the institutional protocol and highlight the need for further prospective studies to determine the optimal strategy for safely reducing bleeding complications in these patients.

Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies

OBJECTIVES/HYPOTHESIS

The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.

STUDY DESIGN

Case series with chart review.

METHODS

Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.

RESULTS

There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).

CONCLUSIONS

Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2069-E2073, 2021.

Screening for undiagnosed bleeding disorders in post-tonsillectomy bleed patients: Retrospective review and systematic review of the literature

OBJECTIVES

There is currently no standard for screening children with post-tonsillectomy bleeds (PTB) for coagulopathy disorders. This study aims to identify children with occult coagulopathy diagnosed at PTB and to identify factors associated with diagnosis. A systematic review of the literature further identified trends in this topic.

METHODS

A retrospective chart review of patients returning to the operating room for PTB at a tertiary children's hospital was undertaken from 2012 to 2016. A systematic review using Medline OVID was subsequently performed.

RESULTS

Of 12,503 tonsillectomies, 311 children (52% male, mean age 8 years) required surgery for PTB (2.5% rate). Twenty-one patients (7%) had multiple episodes. Only two patients (0.6%) (both with known coagulopathy) underwent pre-tonsillectomy labs and 260 (84%) had labs at PTB. Six patients (2%) were diagnosed with a new coagulopathy, most commonly von Willebrand's Disease (vWD) in five (2%). Three patients (1%) were diagnosed at first PTB and three (1%) at second PTB. Of the three diagnosed at second PTB, two had normal partial thromboplastin time (PTT). In systematic review, 1243 manuscripts were reviewed and 8 papers discussing this topic are presented.

CONCLUSION

Occult coagulopathy was rarely diagnosed at PTB, but this may be limited by inconsistent screening. PT and PTT are not sensitive tests for vWD, and normal coagulation labs may lead to delayed diagnosis. The literature reveals occult coagulopathy is rare but often diagnosed after severe or recurrent hemorrhage. In order to provide efficient care and medical management, a standardized algorithm and sensitive labs for screening PTB patients are needed.

Postoperative Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage represents a potentially life-threatening condition that occurs in up to 5% of pediatric patients. Minor bleeding often precedes severe hemorrhage. Patients with minor or self-resolving bleeding should be observed in the emergency department or admitted for monitoring. Patients with severe bleeding should be immediately assessed for airway and hemodynamic stability. Management of severe bleeding includes immediate surgical consultation or initiation of the transfer process to a center with surgical capabilities, direct pressure to the site of hemorrhage with or without the additional of a hemostatic agent, possible rapid sequence intubation, and management of hemodynamic instability with volume resuscitation.

Hemostatic management of patients undergoing ear-nose-throat surgery

Perioperative hemostatic management is increasingly important in the field of otolaryngology. This review summarizes the key elements of perioperative risk stratification, thromboprophylaxis and therapies for bridging of antithrombotic treatment. It gives practical advice based on the current literature with focus on patients undergoing ENT surgery.

Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

Postoperative hemorrhage following adenoidectomy

OBJECTIVES/HYPOTHESIS

To examine postoperative hemorrhage following adenoidectomy.

STUDY DESIGN

Prospective multicenter observational study.

METHODS

The Surgical Instrument Surveillance Programme (SISP) was established in 2003 to monitor tonsil and adenoid surgery in all hospitals in Wales. Data were examined between April 1, 2003 and June 30, 2008, for risk factors that may contribute to primary (R1) or secondary (R2) postoperative hemorrhage from the adenoid bed, of a severity sufficient to require a return to the operating room.

RESULTS

There were 5,588 procedures included, of which 4,225 included simultaneous tonsillectomy. The study included 2,903 (52%) males with a median age of 5.8 years (interquartile range [IQR], 4.5-7.7 years) and 2,685 (48%) females with a median age of 6.5 years (IQR, 5.0-9.1 years). There were 22 patients (0.4%; confidence interval [CI], 0.2-0.6) who returned to the operating room with a postoperative hemorrhage arising from the adenoid bed. These were exclusively R1 hemorrhage; there were no instances of R2 hemorrhage (0.0%; CI, 0.0-0.1). No specific risk factors for R1 hemorrhage could be identified. There were 38 patients in the adenotonsillectomy group who returned to operating room with a postoperative hemorrhage arising from the tonsil bed (0.5%; CI, 0.3-0.8). R1 was seen in 22 patients (0.5%; CI, 0.3-0.8) and R2 in 16 patients (0.4%; CI, 0.2-0.6).

CONCLUSIONS

Adenoidectomy appears to be primarily a procedure performed in childhood. The rate of R1 hemorrhage following adenoidectomy is one in 200 (0.5%) and is similar to the R1 hemorrhage rate for tonsillectomy. R2 hemorrhage following an adenoidectomy appears to be extremely rare. In children, the risk of a serious primary hemorrhage following an adenotonsillectomy is double that of either procedure when performed alone.

Management of children with inherited mild bleeding disorders undergoing adenotonsillar procedures

OBJECTIVE

To evaluate the incidence of perioperative bleeding among children with mild bleeding disorders who underwent adenotonsillar surgery in our hospital and were treated with our perioperative bleeding prophylaxis protocol.

METHODS

Retrospective chart review was aimed at determining the perioperative bleeding rate in children with mild bleeding disorders subjected to our prophylactic protocol while undergoing adenotonsillar procedures. Low von Willebrand factor (LVWF), unspecific platelet function disorders (UPFD) and mild factor VII deficiency were considered as mild bleeding disorders. The protocol utilizes intravenous desmopressin, tranexamic acid, NSAID avoidance, and overnight observation.

RESULTS

Between 2004 and 2009, 44 children with mild bleeding disorders underwent adenotonsillar procedures in our hospital and were treated with the protocol. One patient (LVWF+UPFD) developed perioperative bleeding (2.3%).

CONCLUSIONS

It is possible to obtain low rates of perioperative bleeding in children with mild bleeding disorders undergoing adenotonsillar procedures, provided there is a well-timed diagnosis and an adequate prophylaxis protocol. We believe that further efforts must be directed at preoperative diagnosis of mild bleeding disorders to ensure safer surgeries.

Perioperative incidence and management of hyponatremia in vWD patients undergoing adenotonsillectomy

OBJECTIVES/HYPOTHESIS

To analyze the incidence and severity of hyponatremia in patients receiving synthetic desmopressin (DDAVP) in the perioperative setting of oropharyngeal surgery in the treatment of von Willebrand disease and to propose a standardized protocol for perioperative fluid resuscitation and postoperative sodium monitoring after DDAVP administration.

STUDY DESIGN

Retrospective medical record review.

METHODS

A retrospective medical record review in an academic pediatric medical center was conducted. From October 1, 2002, to February 1, 2009, all patients undergoing adenotonsillectomy and receiving DDAVP preoperatively for the treatment of von Willebrand disease were identified. A total of 76 patients were identified by initial database review; 63 patients were included in the study, and 13 patients were excluded secondary to incomplete data. DDAVP dose and timing, perioperative fluid volume and composition, and postoperative sodium levels were collected. Extreme adverse events related to hyponatremia were recorded.

RESULTS

Forty-seven of 63 (74.6%) patients developed some degree of hyponatremia after DDAVP administration, and six of 63 (9.5%) patients developed extreme hyponatremia, with the degree of hyponatremia related to the volume of perioperative fluid resuscitation. The sodium nadir occurred within 9 to 20 hours after DDAVP administration. No serious adverse events related to hyponatremia were recorded during the study period.

CONCLUSIONS

The incidence of hyponatremia in children receiving DDAVP for prophylaxis of intraoperative bleeding following oropharyngeal surgery is high. The degree of hyponatremia is related to the perioperative fluid volume administered. A protocol for DDAVP administration, perioperative fluid resuscitation, and postoperative sodium monitoring that aims to reduce the incidence of hyponatremia in this population is proposed.

Incidence of bleeding complications in pediatric patients with type 1 von Willebrand disease undergoing adenotonsillar procedures

OBJECTIVE

To review the incidence of postoperative bleeding in children with type 1 von Willebrand disease (VWD) who were treated with a single institution protocol.

STUDY DESIGN

We performed a retrospective study to determine the postoperative hemorrhage rate in pediatric patients with type 1 VWD who were treated via the Children's Hospital of Philadelphia institutional protocol. This protocol utilizes intravenous desmopressin (DDAVP), oral aminocaproic acid, and overnight observation.

RESULTS

Between the years of 2000 to 2006, 41 children with type 1 VWD underwent an adenotonsillar procedure and were treated with this protocol. Seven patients (17%) experienced delayed (>24 hours after surgery) postoperative hemorrhage requiring intervention. Five of the 7 patients required cautery to control the bleeding, and the remaining 2 patients responded to DDAVP and aminocaproic acid alone. Older age and lower VW antigen levels were associated with postoperative hemorrhage (P = .05).

CONCLUSIONS

Despite therapeutic intervention to decrease the risk of postoperative hemorrhage, the incidence of hemorrhage was higher in pretreated patients with type 1 VWD than in children without bleeding disorders. Further prospective studies are necessary to determine the optimal treatment to reduce bleeding complications in these patients.

Preoperative coagulation screening for adenotonsillectomy: A review and comparison of current physician practices

Objective: To determine the current practice of pediatric otolaryngologists on a national level and general otolaryngologists on a regional level regarding preoperative coagulation screening prior to adenotonsillectomy.

Study design: A five-question survey of members of the American Society of Pediatric Otolaryngology (ASPO) and the Massachusetts Society of Otolaryngology–Head and Neck Surgery (MSO-HNS).

Subjects and methods: Survey results were analyzed to determine current preoperative screening practices relative to awareness of screening recommendations published in the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) 1999 Clinical Indicators Compendium.

Results: The survey response rate was 27 percent (54/190) and 29 percent (76/260) for MSO-HNS and ASPO members, respectively. In patients with no known bleeding risk, 21 percent of respondents continue to obtain coagulation screening including, at a minimum, a partial thromboplastin time and a prothrombin time. MSO-HNS respondents reported ordering more preoperative coagulation studies than did ASPO respondents (35% vs 10%). Interestingly, awareness of the AAO-HNS consensus statement was similar between the two groups and did not impact screening practices.

Conclusions: The survey results indicate a discrepancy between current practice relative to pre-adenotonsillectomy coagulation screening and the recommendations of the AAO-HNS 1999 consensus statement.

The prevalence of bleeding disorders among healthy pediatric patients with abnormal preprocedural coagulation studies

BACKGROUND

We evaluated the prevalence of hemostatic disorders among pediatric patients with abnormal screening coagulation tests.

PROCEDURE

We analyzed 48 consecutive referrals for abnormal prothrombin times, partial thromboplastin times, or closure times obtained as preprocedural screens. Patients were evaluated by uniform diagnostic testing.

RESULTS

Seventeen patients (35%) had an isolated nonspecific inhibitor (NSI). Six patients (12.5%) presented with mildly low factor activity with a concomitant NSI. These deficiencies were of unclear clinical significance. One patient (2%) had a lupus anticoagulant. Only 9 patients (19%) had a possible or true mild bleeding disorder: 5 patients (10%) had isolated low von Willebrand factor levels, 2 patients (4%) had possible type I von Willebrand disease, and 2 (4%) had platelet aggregation disorders. In all patients, personal and family bleeding history had a positive predictive value of 45% for hemostatic disorders.

CONCLUSIONS

The most common diagnosis among the patients referred to us for abnormal preoperative coagulation tests was a NSI, which is not associated with an increased risk of operative bleeding complications. Less than 20% had a possible or true mild bleeding disorder. Although certain bleeding disorders can be occult in children and are associated with perioperative bleeding risks, our study demonstrates the inherent limitations in making a laboratory diagnosis of a bleeding disorder in pediatric patients preoperatively. Our findings contribute to existing doubt about the usefulness of prothrombin times, partial thromboplastin times, and closure times to identify occult bleeding disorders in this population.

Risiko von Blutungen nach Adenotomie und Tonsillektomie

BACKGROUND

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement - at least for children - routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder ( http://www.hno.org/kollegen/gerinnung_te_ae.html ). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

PATIENTS AND METHODS

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

RESULTS

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

CONCLUSION

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.